Healthwatch: On the board toolkit

Developing skills for effectiveness on health and wellbeing boards Acknowledgements

The Local Government Association (LGA) is grateful to all those board members and others from councils and local Healthwatch who participated in interviews, focus groups and provided information for case studies and made suggestions for issues to be covered in this tool.

We would like to acknowledge that this tool builds upon a previous publication ‘Local Healthwatch and health and wellbeing boards’ created by Healthwatch Dorset in collaboration with Patient Public Involvement Solutions LTD. Foreword

Involving local residents in decisions on their own health and social care services is crucial for us to be able to provide services that meet their needs. There can be nothing more important than the health and wellbeing of our residents.

Engaging communities is a key challenge for health and wellbeing boards as they begin to move fully into their role as strategic leaders for health, social care, and wellbeing systems in their local areas. Independent from health and social care systems, local Healthwatch representatives on the board are in a unique position in ensuring that this is done well. However, this is no small task and as a new organisation in the system the challenge for local Healthwatch is to build strong working relationships with their fellow board members, be able to have difficult conversations, and present the views of our local residents in a way that is impactful on the decision making process.

Being both a collective leader in the health and social care system and providing challenge on the board where necessary requires a great deal of skill and knowledge, but the end goal of shaping the health and wellbeing services of the future and improving the health of local people is worth the effort needed to get this right.

I am delighted to introduce this toolkit for local Healthwatch representatives which we hope will support you in building effective relationships and strengthening your position as a collective strategic leader on the board.

Caroline Tapster Director: Health and Wellbeing System Improvement Programme LGA

# Contents

1. Introduction 07

2. Local Healthwatch’s role on health and wellbeing boards 08

3. Skills, accountabilities and relationships 10

   - Local leadership 10
   - Partnership working and accountability 11
   - Communication and engagement 11
   - Political understanding 13
   - Scrutiny and challenge 14
   - Where to go for support? 16

4. Reflective leadership tools 17

5. Helpful terms and phrases 21

6. Introduction

This toolkit is part of the LGA’s ‘Healthwatch: On the Board’ series, designed as a learning aid to support local Healthwatch representatives on their health and wellbeing board (HWB). Local Healthwatch have an important collective leadership role on boards; as boards shift from development to delivery it is more important than ever to ensure that Healthwatch representatives are well supported to carry out this role as effectively as possible to ensure service users can contribute a vital role in the local health and wellbeing landscape.

A recent review of HWBs by Shared Intelligence found a need for boards to develop the capacity to visibly and effectively drive the immediate tasks of health and social care integration and health service reconfiguration. The review identified three tasks to achieve this paradigm shift:

• tighter prioritisation • more effective engagement • driving change on the big issues.

The toolkit provides:

• guidance on the skills the local Healthwatch representative needs to effectively represent the local Healthwatch on the HWB • tools that representatives can use for self-development of leadership capacity.

It will support Healthwatch representatives in their dual role; first, to bring the voice of the local community to the HWB by leading more effective engagement; and second as a system leader, influencing decision making and commissioning and supporting the development of the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS) and helping to drive the change that is required. 2. Local Healthwatch’s role on health and wellbeing boards

HWBs are statutory bodies introduced by the Health and Social Care Act 2012 (the Act). All upper tier and unitary authorities are required to have a health and wellbeing board and they are statutory committees of the local authority. The ambition underlying the introduction of health and wellbeing boards was to build strong and effective partnerships which would lead to improved commissioning and delivery of health and social care services across the NHS and local government. In turn this will lead to improved health and wellbeing outcomes for local communities.

The Act prescribes the core statutory membership of health and wellbeing boards http://www.local.gov.uk/c/document_library/get_file?uuid=1ccc06cb-d44b-43c6-b04c-f7b713e03122&groupId=10180. While there is a core statutory membership, councils can also decide to augment the membership on either a permanent or temporary basis, to include for example, district councils or the police and crime commissioners. Membership may be flexible depending on the priorities of the board. Voting powers too may vary from council to council. Not all boards will extend voting powers to Healthwatch representatives (along with other non-elected members and officers), and you will need to check the position on your board. If your board does give voting powers to all members, then as a Healthwatch representative, it will be important for you to demonstrate that collective responsibility, even if you dissent from the views of other members. A number of local Healthwatch representatives have expressed the view strongly that Healthwatch needs to participate in the collective responsibility of the board. Voting powers can act as a lever for influencing and shaping future services. You will need to ensure that in voting you fully represent the views of patients, service users and the public even if this position is to abstain.

Health and wellbeing boards have a duty to prepare a Joint Strategic Needs Assessment (JSNA) and a Joint Health and Wellbeing Strategy (JHWS). The JSNA identifies the current and future health and wellbeing needs of the local community and the JHWS says how these needs will be met. Both should be living documents, under continuous review to ensure that they meet changing needs of local communities. In preparing these documents, boards will need to consider the views of local people and users of health and care services and carers. The Healthwatch representative has a key role to play to lead and coordinate the board’s shared responsibility to ‘hardwire’ the patient, service user and carer voice into the JSNA and JHWS. Because Healthwatch is independent from health and social care organisations and through its contact with patients, service users and carers. It can develop the insight and evidence to highlight the issues that matter most to local people. In order to provide that strong local voice there needs to be good two-way communication with the local health and wellbeing board, presenting evidence of the patient, service user and carer voice to, and feeding back information from the board. Figure 1 below, sets out how all key stakeholders have a role to play in informing both the JSNA and JHWS.

**Figure 1**

In addition the HWB has a responsibility to undertake a Pharmaceutical Needs Assessment (PNA); often this will form part of the JSNA. Boards are also required to sign off local proposals for the Better Care Fund (BCF). The BCF [http://www.local.gov.uk/web/guest/search/-/journal_content/56/10180/3905294/ARTICLE](http://www.local.gov.uk/web/guest/search/-/journal_content/56/10180/3905294/ARTICLE) is a pooled budget that shifts resources into social care and community services for the benefit of the NHS and local government.

**Checklist:**

- Is the membership of the board restricted to the core as set out in the Health and Social Care Act 2012?
- Does the council flex its membership depending on the board priorities?
- Do you have voting powers? If so, do you always ensure that you use your vote?
- How do you ensure that the views of patients, service users and the public are represented in the board decision making process?
- Are the board’s priorities focussed, or is there a danger of ‘mission creep’ and taking on too large a role?

3. Skills, accountabilities and relationships

To be effective in your role, as in any job, you need to understand what is required and what skills are needed. A useful role description can be found in the Dorset Toolkit. Although there is no single ‘right’ way, there are a number of core skills that will aid you to be a more effective and influential member of the board.

Local leadership

In the context of your role on the board, leadership is not about taking power or control, but ensuring the right environment for action. It is about stimulating, enabling and empowering partners; having a shared vision and a joint commitment to delivering it. Leadership is integral to achieving strong and effective partnership working both within the health and wellbeing board and between the board and provider organisations. Good leadership is also about the ability to tackle difficult decisions and reach agreement on contentious issues. Strong local leadership will enable challenges to be resolved without impacting negatively on either the board or the wider community. There are a number of different leadership styles and one size does not fit all but democratic or participatory leadership fosters better two way engagement; this can be a very helpful approach to understand insights, gain buy-in and encourage a team approach, particularly where the decisions may be challenging. It is important to remember that Healthwatch representative have parity of esteem and a focus on collective leadership with other board members.

Checklist:

- Is decision making, commissioning and budget setting fully integrated within the whole system, rather than individual outcome measures?
- Are the links to other council and clinical strategies clear and is the board leading improvements in service change and reconfiguration?
- How does a particular proposal fit with the overall strategic plan for the board?
- How as a local leader do you bring the patient voice to the decision making process?

Case Study: London Borough of Richmond Healthwatch – establishing relationships

The Chair of Richmond Healthwatch recognised that as a start-up there was a need for the local Healthwatch to establish credibility and demonstrate leadership. They have taken time to develop relationships with other local leaders within the health and social care sector, particularly the Clinical Commissioning Group, (CCG) and local authority leaders, meeting with them on a one to one basis. They have also looked for opportunities to provide support for the health and wellbeing board and to provide local leadership. This has included a communications and engagement event for local stakeholders. Despite holding a senior full time role, the chair makes attendance at the board a priority, but also ensures that roles and opportunities to strengthen engagement further are shared among other board members. For further information contact: Mike Derry 020 3178 8784. Partnership working and accountability

Strong relationships with others are the foundation for achieving positive outcomes for the local community. The health and wellbeing board provides the accountability for joint working across the health and social care sector. Partners are not just statutory members of the health and wellbeing board, but include provider organisations, the voluntary and third sector, and other system players. Research by the King’s Fund and Shared Intelligence found that many boards thought that strong working relationships were the most important factor in achieving their objectives. In developing strong relationships you will be able to identify and work collaboratively to achieve shared goals. This will not just occur within the formal context of the board meetings, but can take place in informal settings. They may be workshops with stakeholders, focus groups with specific service users or shared learning through peer to peer relationships.

Strong relationships do not necessarily require the partners to agree, but they will involve identifying conflicting objectives and building a culture of trust. A strong partnership will also have the capacity to have ‘difficult conversations’ and be more effective. Relationships that become too ‘cosy’ will not necessarily achieve the best outcomes for your local community. The roles, relationships and accountabilities within the local health and social care sector are complex and may involve potential conflicts of interests. A key skill is to work hard at these relationships and understand the contribution that each of the partners can make and that you are all accountable for the decisions of the board. In this way you will gain more clarity around your role and the value you can add to the board. An open and transparent decision making process, combined with a culture of ‘no surprises’ can help to manage these relationships and ensure better outcomes. In that way positive relationships and high level strategy can be used to develop tangible outcomes and positive benefits for the local community.

Checklist:

• Is there a clear vision by all board members and how does the board’s work benefit patients, service users and carers? Is there a shared political and clinical resolve to deliver that vision?

• Do other members of the health and wellbeing board understand the purpose of Healthwatch and that as the Healthwatch representative you are accountable to your local community? As such you will need to ensure that any decisions you take will be in consultation with them.

• What format is the meeting? Is there a formal agenda, or are there more informal meetings, allowing time and space to develop priorities and review performance?

Communication and engagement skills

Strong communication skills are a prerequisite for good leadership. Good communication will mean ensuring that the board understands fully the perspective of patients, carers and service users, based on intelligence and evidence that you have gathered. So how you communicate with patients, service users and carers, means recognising the many different settings, and being able to listen sensitively and use appropriate language with different groups. Whatever means of communication, using simple language to give the patient or service user a voice within the formal setting of the board is essential.

Good engagement involves more than just effective communication. One of the key roles of the health and wellbeing board is to ensure effective commissioning of health and social care services for their area. This can only take place in the context of comprehensive engagement at every stage of the process with local communities, including people who use services, carers and the voluntary and community sector. As a local leader your role within Healthwatch is to make sure that the board understand the importance of qualitative evidence as well as quantitative data, bringing the patient and service user voice to the decision making process.

**Case Study: Shropshire – Memorandum of Understanding**

Shropshire’s health and wellbeing board, Shropshire Council Overview and Scrutiny Committee, and Healthwatch Shropshire have created a ‘Memorandum of Understanding’ [http://shropshire.gov.uk/committee-services/documents/s2820/OSC-HW-HWBB%20Memorandum%20of%20Understanding%202.pdf](http://shropshire.gov.uk/committee-services/documents/s2820/OSC-HW-HWBB%20Memorandum%20of%20Understanding%202.pdf). It sets out how the organisations will work together to involve patients and the general public in improving health and social services in the county.

The main principles agreed in the document are:

- to promote the safety, health and wellbeing of the Shropshire population
- to hold each other to account for decisions and delivery
- to respect each other and each organisation’s independence
- to maintain public confidence by engaging and communicating with the communities we serve
- to consistently promote openness and transparency
- to use resources efficiently and effectively.

Jane Randall-Smith, chief officer of Healthwatch Shropshire, said:

“Healthwatch Shropshire is a full member of the health and wellbeing board and participates in the meetings to represent the views of the people of Shropshire.

“One of our roles is to make sure that people’s opinions are heard by the service providers and commissioners to enable change. This Memorandum of Understanding will underpin the way we work together, which should help even more people’s views get heard in the future.”

Contact Jane Randall-Smith: 01743 237 884

**Checklist:**

- How have patients, service users and the public been involved in any proposals?
- Has the proposal been tested with relevant stakeholders?
- What use does the board make of qualitative evidence such as patient stories?
- How has your Healthwatch demonstrated that its contribution has resulted in real change at Board level? Case Study: Bath and North East Somerset – working in partnership

Bath and North East Somerset Healthwatch manages a health and wellbeing network, which is open to all local providers as well as other groups such as community organisations and stakeholders. The network meets shortly before the HWB and acts as a forum for key board priorities to be discussed with recommendations then fed back to the board.

These arrangements have been welcomed by providers. Janet Rowse, Chief Executive of Sirona Care and Health, says the engagement process has helped create a sense that providers are taking part in a “joint endeavour”.

Contact: Andrea Wolfenden, strategy development officer, andrea_wolfenden@bathnes.gov.uk

Case Study: Healthwatch Devon – engaging stakeholders

The experience at Devon Healthwatch over the last year is that there has been a process of settling in, while most if not all parties to the HWB are working out their respective roles and functions. Sometimes this has meant that we have been unsure how best to report to the board, and how to get the consumer voice heard.

More recently, the board has agreed a key theme for each of its meetings, linked to the health and wellbeing strategy. This has enabled Healthwatch to be much clearer about how to use the information to generate discussion. It helps Healthwatch to:

• tell Devon residents, via monthly e-bulletins, what themes future boards will address, and how they can feed in to the Healthwatch reports • talk with delivery partners (voluntary organisations that are in touch with key groups of health and care service users) about how they can get relevant input from their audiences (eg people with learning disabilities, carers, etc) • give feedback to all stakeholders about how the Healthwatch reports were received by the Board and what discussions and decisions ensued.

Healthwatch are now more confident that board members understand the qualitative evidence that Healthwatch can bring, and the that way case studies built on people’s front-line experience of health and care services can provide insights that statistics alone cannot.

Contact: Miles Sibley, Executive Director: miles@healthwatchdevon.co.uk

Political understanding

The health and wellbeing board is a formal committee of your local authority. All upper tier or unitary authorities are required to establish a board. The vast majority of councils are run by a leader and cabinet, or by an elected mayor. http://www.local.gov.uk/web/guest/search/-/journal_content/56/10180/3905294/ARTICLE

Political systems and processes underpin all decision making in local government. So understanding the processes, both formal and informal, through which decisions are taken is essential in being able to influence outcomes. Political understanding recognises that there are different arrangements in different areas. Understanding who are the local political leaders and the political control and systems under which the local authority operates is a key skill for effective board membership, so is understanding the role of the cabinet, or lead member, the overarching council objectives and how they relate to the objectives of the health and wellbeing board.

The Localism Act 2011 has allowed councils, where they wish, to move away from an executive form of governance to a committee system. A number of councils have now adopted, or are considering, moving to a committee system. For some of these councils a committee system means that there are no longer any scrutiny committees; for example, Cambridgeshire County Council has a small number of service committees which also take on the scrutiny function. In Nottinghamshire, however, a separate Health Scrutiny Committee was established almost immediately following the establishment of the new structure in May 2012.

Checklist:

• What system does your council operate under – cabinet or committee? • Is there a separate Scrutiny Committee for Health and Social Care? • Do you understand your council’s decision making process? • Who are the key local leaders in the council? • How do the priorities of the board fit with other council strategies, for example the council’s financial plan, or the children’s plan? Is there a clear alignment between council priorities and those of the board? When bringing the patient’s voice to the table are you making sound and coherent links to the appropriate strategies?

Scrutiny and challenge

The Health and Social Care Act 2012 introduced some significant changes to the way in which health and social care services are held to account. Setting up of Healthwatch, with its role as the champion of patients, service users and carers, embedding public insight, was just one aspect of the new landscape. Scrutiny and challenge is an important day-to-day aspect of your role on the board. You will be a critical friend providing constructive challenge and feedback while at the same time fulfilling a collective leadership role on the board. To be effective in this role, you will need to analyse information quickly and present arguments that are concise, meaningful and easily understood. Where councils still have a separate Health Scrutiny Committee there is potential tension between the different roles of local Healthwatch, the health and wellbeing board and the Scrutiny Committee. While Healthwatch is a full member and participates in the decisions made by the health and wellbeing board, it may also support the local scrutiny committee to scrutinise those very decisions, by providing information and local intelligence. Case Study: Healthwatch Cambridgeshire – navigating the committee system

In Cambridgeshire a change in political control in 2013, to no overall control, followed by a return to the Committee system of governance, provided additional challenges for Healthwatch. Multiple change agendas being driven from different perspectives; the CCG Older People and Adult Community Services (OPACS) Contract, Better Care Fund and the ‘challenged health economy’ redesign work along with the complexity of the commissioning arrangements have made any in-depth understanding of the whole system a challenge, even for the long-standing and well-informed councillors. Added to this the return to the committee system, no overall control, changing chairs and reducing officer time has made the liaison between overview and scrutiny and the health and wellbeing board even more complex.

Addressing these challenges through relationship building has been key; this is done by the Healthwatch Cambridgeshire (HWC) Chair at HWB board meetings and development sessions and in parallel by the HWC CEO in her role in the HWB Officer Support Group. There is close liaison between the two to ensure effective input. The CCG and HWC successfully lobbied the local authority to have a distinct and separate health scrutiny function. They both felt strongly that the health agenda is so complex and developing so rapidly that the scrutiny function could not be effectively carried out by the County Council Adults Committee.

Healthwatch challenges board discussions in light of people’s experiences and highlights the benefits of meaningful dialogue with patients and public in all change agendas. They have pressed for the HWB development days to include all aspects of CCG strategic planning and asked for providers to be involved wherever possible. As a result relationships are excellent between HWC and other board representatives. Healthwatch feels that their view is respected and they are invited to contribute toward all strategic agendas.

The Chair of Healthwatch Cambridgeshire says “Get to know your councillors and raise their awareness of Healthwatch Offer Briefing Sessions and make sure they know how people can raise concerns. Providing input into JSNA planning is a way of making sure that community experience and public voice feature strongly in JSNAs.”

Contact: Sandie Smith, Chief Executive, Healthwatch Cambridgeshire: sandie.smith@healthwatchcambridgeshire.co.uk

Checklist:

• Are you expected to report regularly to your Scrutiny Committee?

• How do you separate your leadership role on the health and wellbeing board with your responsibility for scrutiny and holding to account on behalf of patients and service users?

• Does the Scrutiny Committee look to Healthwatch to provide the patient voice and how do you ensure that this happens? Case Study: Warwickshire – clarifying relationships

Warwickshire Health and Wellbeing Board has sought to clarify the roles of four key bodies – the HWB, Healthwatch Warwickshire (HWW), the Children and Young People Overview and Scrutiny Committee, (CYPOSC) and the Adult Social Care and Health Overview and Scrutiny Committee, (ASCHOSC).

A ‘memorandum of understanding’ has been signed by the chairs of the four groups to establish a “clear working relationship”. It committed the bodies to share information, respect each other’s independence and cross refer concerns.

For example, HWW has promised to produce regular reports and advice to the ASCHOSC. Meanwhile, the HWB has committed to consulting both scrutiny committees on the development of the joint strategic needs assessment and health and wellbeing strategy. The ASCHOSC has also pledged to scrutinise the work of HWW via six-monthly reports and both committees have agreed to commission HWW to carry out reviews when appropriate.

Contact: Paul Spencer, democratic services officer: paulspencer@warwickshire.gov.uk

Where to go for support?

While all of the above should support you in your role, there may be occasions when you feel that your contribution is not making the impact that you hoped. You will probably not be alone. In such circumstances your regional networking groups might well provide the support and inspiration that you need. You could also set up a small action learning group, or use Yammer to share ideas and best practice. The LGA has produced a useful guide to health and wellbeing http://www.local.gov.uk/documents/10180/5854661/A+councillor’s+guide+to+the+health+system+in+England/430cde9f-567f-4e29-a48b-1c449961e31f and Healthwatch England policy and development teams should also be able to offer support. 4. Reflective leadership tools

All members of the board will approach their role in different ways and there is no single right way to undertake the role of Healthwatch representative. Many organisations find that a simple model with prompts can help to embed a culture of continuous learning and improvement. Figure 2 suggests a model for continuous reflection and review of performance on and with the board.

**Figure 2**

Using the skill set as a template, there are a number ways in which you can measure how you are fulfilling your role as the local Healthwatch representative using the prompts above and the checklist below.

### Local leadership

| What are my strengths? | Some prompts: | |------------------------|--------------| | | How well do I understand my role and that of other board members? | | | How do I change my leadership style to adapt to different situations? | | | How do I support and empower others? |

| What examples illustrate my strengths? | |----------------------------------------|

| What would I like to do to improve? | |-------------------------------------|

### Partnerships and accountability

| What are my strengths? | Some prompts: | |------------------------|--------------| | | Who are my key strategic partners and what networks have I developed? | | | What mechanisms do I use to build strong partnerships? | | | How do I respond to differing views? | | | How do I demonstrate accountability to the board and to patients, service users and carers? |

| What examples illustrate my strengths? | |----------------------------------------|

| What would I like to do to improve? | |-------------------------------------|

### Communication and engagement

| What are my strengths? | Some prompts: | |------------------------|--------------| | | How do I engage with patients, service users, and carers? | | | How do I engage with hard to reach groups? | | | How do I champion their needs? | | | How do I reconcile conflicting priorities between different groups? | | | How well do I listen and hear what others are saying? |

| What examples illustrate my strengths? | |----------------------------------------|

| What would I like to do to improve? | |-------------------------------------|

### Political understanding

| What are my strengths? | Some prompts: | |------------------------|--------------| | | How well do I understand my local political landscape? | | | Do I understand the political structures and the roles of the relevant cabinet members and/or mayor and leader? | | | Do I know how the JHWS fits with other council strategies? | | | Do I keep up to date with policy making and development? |

| What examples illustrate my strengths? | |----------------------------------------|

| What would I like to do to improve? | |-------------------------------------| | Scrutiny and challenge | |------------------------| | **What are my strengths?** | Some prompts:\
How do I use scrutiny and challenge to achieve better outcomes?\
Are my arguments always concise, meaningful and easily understood?\
Am I constructive in my criticism?\
Am I fair, objective and rigorous when challenging processes or people?\
How do I monitor performance and how do I deal with poor performance? | | **What examples illustrate my strengths?** | | | **What would I like to do to improve?** | | 5. Helpful terms and phrases

Below is a list of terms and phrases that you may come across on the health and wellbeing board. Many provide links where you can find more information to help you in understanding the language of the health and social care system.

**Better Care Fund.** The £3.8 billion Better Care Fund (BCF) was announced by the Government in the June 2013 Spending Round, to support transformation and integration of health and social care services to ensure local people receive better care. The BCF [http://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE%20/l%20"sthash.lc25ir6R.%20dpuf](http://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE%20/l%20%22sthash.lc25ir6R.%20dpuf) is a pooled budget that shifts resources into social care and community services for the benefit of the NHS and local government.

**Clinical Commissioning Group** CCGs bring together local GPs and experienced health professionals to take on commissioning responsibilities for local health services. As commissioners of hospital and community health services, a CCG is responsible for planning the right services to meet the needs of local people, buying local health services including community health care and hospital services, and checking that the services are delivering the best possible care and treatment for those who need them. They are overseen by NHS England. More information about the CCG in your area can be found at NHS England’s website [http://www.nhs.uk/NHSEngland/thenhs/about/Pages/ccg-outcomes.aspx](http://www.nhs.uk/NHSEngland/thenhs/about/Pages/ccg-outcomes.aspx).

**Joint Health and Wellbeing Strategy** JHWSs are strategies to meet local population’s health and wellbeing needs identified in JSNA. They are not one-off documents but are a live, continuous process of strategic assessment and planning, which in a two-way relationship will build on and inform other local assessments and strategies. They do not stand alone but are a vital part of the local array of strategies, reports and assessments, including: the director of public health’s annual reports; clinical commissioning groups’, needs assessments; child poverty strategies; community strategies; local economic assessments; and strategic housing market assessments.

**Joint Strategic Needs Assessment** JSNAs analyse the health needs of populations to inform and guide commissioning of health, wellbeing and social care services within local authority areas. It underpins the health and wellbeing strategies. The main goal of a JSNA is to accurately assess the health needs of a local population in order to improve the physical and mental health and wellbeing of individuals and communities.

**Lower tier authority** also known as district, borough or city councils, they manage services including: rubbish collection and recycling, Council Tax collections, housing and planning applications.

**Marmot Principles** a review under the leadership of Professor Sir Michael Marmot, published in February 2010, found a ‘social gradient’ in health (meaning that ‘the lower a person’s social position, the worse his or her health’). Six specific policy objectives were recommended: • create and develop healthy and sustainable places and communities • create fair employment and good work for all • enable all children, young people and adults to maximise their capabilities and have control over their lives • ensure healthy standard of living for all • give every child the best start in life • strengthen the role and impact of ill health prevention.

NHS Act 2006 s75 The Act provides for local authorities and NHS Bodies to enter into arrangements to improve the way in which their functions are exercised. Statutory guidance on aligned and pooled budgets can be found on the government website https://www.gov.uk/government/publications/the-7-principles-of-public-life/the-7-principles-of-public-life--2.

NHS England The board was formed as part of the NHS reforms in the Health and Social Care Act 2012. It became NHS England in March 2013 and has a wide range of powers and functions including commissioning primary care and specialised services, supporting quality improvement promoting innovative ways of demonstrating how care can be made more innovative and delivering improved outcomes. More information about NHS England and its commissioning role can be found on the NHS England website.

Nolan Principles The seven principles of public life apply to anyone who works as a public office-holder. This includes people who are elected or appointed to public office nationally or locally. They were first set out by Lord Nolan in 1995. The seven principles are: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. More information on the guidance can be found on the government website.

Outcomes Frameworks set the indicators for measuring outcomes within health and social care. They exist for the NHS https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/256456/NHS_outcomes.pdf, Adult Social Care https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/263783/adult_social_care_framework.pdf and Public Health http://www.phoutcomes.info/. There is a further Outcomes Framework to support the commissioning of children’s services.

PCC Police and Crime Commissioner PCCs were elected for the first time in November 2012, replacing Police Authorities. Their role is to hold the Chief Constable and force to account and to ensure an efficient and effective police service in their area. They set the police and crime objectives for their area through a police and crime plan and through that the force budget. They bring together community safety and criminal justice partners to make sure local priorities are joined up.

Pharmaceutical Needs Assessment The Health and Social Care Act 2012 transferred responsibility for developing and updating of PNAs to health and wellbeing boards. Each health and wellbeing board must assess needs for pharmaceutical services in its area, and publish a statement of its first assessment and of any revised assessment.

Unitary authority or metropolitan and London boroughs are responsible for all the services provided by upper and lower tier authorities.

Upper tier authority Usually known as county councils, they are responsible for services across a county including: education, transport, strategic planning, public safety including trading standards, social care, libraries and waste management.